Two weeks in Humboldt County, Calif.: Insight into rural medicine

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

As part of the family medicine clinical rotation here at Stanford, students have the option of spending two weeks doing a “rural medicine” track in Humboldt, a small 150,000-person county that is about a 5- to 6-hour drive north of Palo Alto. Each month, up to two medical students can volunteer to be in Humboldt, and Stanford takes care of arranging for hosts, clinic preceptors, and pretty much everything else. I had heard from upperclassmen that this track was “amazing” and “unique” and that I should “do it!!!” And so, three weeks ago, I found myself downloading an audiobook version of Aziz Ansari’s Modern Romance to keep me company as I made the long drive to Fortuna, California.

I’m not sure what I expected to see when I got there. For some reason, I had this dramatic idea that I would be spending two weeks with no cell phone service, spotty access to Internet, no Starbucks visible in a 10-mile radius, and paper medical records instead of an EMR. The reality wasn’t quite so bleak (in fact, the very first sign I saw in Fortuna pointed toward a Starbucks, and I had zero trouble with cell phone service and Internet access), but it was still a jarringly different experience from my first three months of rotations, spent in Palo Alto and Santa Clara.

First and most noticeable was the shortage of physicians. Everyone talks about the physician shortage and the need for primary care physicians, but it wasn’t until I got to Humboldt that I first saw this need manifest. In the clinic where I was working, there was one family medicine physician - total. Each day, he saw 25 or more patients and did everything from diabetes care to trigger point injections to skin cancer. There were poignant moments in clinic, when it was clear that a patient needed specialist care, but there simply wasn’t anyone to refer the patient to. The nearest specialist care center was UCSF, five hours away. Moreover, it was sometimes difficult to access patients' past medical records, or records from other clinics. The EMR in Fortuna was just a few years old, and in fact, there was one day of clinic when my preceptor and I explicitly dedicated time to transferring patients’ past medical history from paper records into the EMR.

Contrast this to the second half of my family medicine rotation, which I spent at a Stanford-affiliated clinic. Over the course of 1 week in this clinic, I worked with five different family medicine preceptors, and there were still more physicians at the clinic with whom I had not worked with directly. We saw between 12 and 15 patients a day and had the luxury of scheduling in 40-minute time blocks whenever a patient needed the extra time. I had no trouble accessing patient’s medical records, not only within Stanford but from outside institutions they had been seen in in the past. Test results popped up in Epic (Stanford’s EMR) in a timely manner, with lovely color-coded labels and notifications whenever a patient was due for a vaccine. And when we needed specialist care, it was just a click away.

If I’m honest with myself (and I hope I don’t regret saying this publicly), I felt much more at ease in the latter clinic environment, where I was able to pend orders for any test I thought a patient needed, trend patients’ lab values, and declare confidently that I thought a patient could benefit from such-and-such specialist care, knowing that it was a viable option rather than a hopeful suggestion. My first two years of medical school trained me to think about what diagnoses were possible, then immediately what labs and imaging studies were needed to work these diagnoses up. I was lost in the world of rural medicine when sometimes the test to work something up was not an option. My time in Humboldt gave me much-needed perspective – not only into how far medicine has come but also what medicine was once like, and where I stand in the middle of it all.

Hamsika Chandrasekar is a third-year student at Stanford’s medical school. She has an interest in medical education and pediatrics.

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